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SNI Digital, Innovations in Learning, in association with the UCLA
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Department of Neurosurgery, Lindy Leow, the chairwoman, and its faculty are pleased to bring to you the UCLA Department of Neurosurgery 101 lecture series on neurosurgery and clinical and basic
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neuroscience.
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This series of lectures are provided free to bring advances in clinical and basic neuroscience to physicians and patients everywhere.
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One out of every five people in the world suffer from a neurologically related disease This lecture and discussion will be on the evolution of US neurosurgery resident education.
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A brief look back. a long look at the present and a preview of the future. It will be given by Richard Byrne, the Roger C. Bohm Presidential Professor, and Chairman of the Department of
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Neurosurgery at Rush University Medical Center in Chicago, Illinois.
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Today, I'm very pleased to announce that we have a visiting professor, Dr. Richard Byrne Aaron is the Roger C. Bohm Presidential Professor and Chair of the Department of Neurosurgery at Rush
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University. I learned last night that he's been chair for 18 years, so you must have started when you were 30.
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He actually did his MD at Northwestern and then just residency at Rush, and then pretty much has stayed there ever since And
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he's just really a very, I would say, probably a Renaissance person within neurosurgery. He's published over 150 papers. and various book chapters and textbooks. He is co-PI of an NINH funded
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intracortical visual prosthesis clinical trial for the treatment of blindness, which we may hear a little bit more about today. And he's also been very active in neurosurgery. He's been the
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president of the NSA. He's a director of the ABNS. He's been on the board of the CNS. He's currently on the board of directors of the ABNS of the AANS And he was treasurer of the SNS and will be
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president or actually is president elect of the SNS, which is our, you know, our national educational society. So, you know, it's actually I'm very interested to hear his first talk, which is
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on the evolution of US. neurosurgical residency education. So, let's give Dr. Byrne a warm welcome.
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Thanks everyone for the invitation Linda. Thank you very much the invitation. It's an honor to be with you. I know the faculty here pretty well. I've interviewed I think roughly a third of the
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residents. So I've gotten to know a fair amount of the residents as well. I've never been to the campus. It's very impressive. This is a really top flight residency program and it's an honor to be
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invited here I've got two talks for you today. The first one is really meant to inform the residents of what you're going through and to maybe get the faculty caught up in all the changes that have
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happened in US. neurosurgery education in the last decade. And then hopefully to stir up a little bit of debate about what's been good, what hasn't been good, what's going to happen in the future
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and just to get people talking one is just pure fun. The second one is really just to inspire the residents. to get involved in the artificial intelligence revolution that's about to happen here.
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So let's go ahead and get started. These are my disclosures. As Linda pointed out, I've seen resident education from every possible angle as a resident department director, department chair for 18
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years. And then the variety of things that I've done with Linda and Langston and others in national neurosurgery. So I'm going to try to give all those perspectives, leaning more towards the
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national perspective to explain why some things happen.
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I also have gone through the entire SNS archives. So I'm going to have some
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references to the archives from the old days just for fun and just to give you some perspective. I'm going to be referencing these seven papers that I was co-author on in the last three years on US
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neurosurgery education
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and these websites. These are all publicly available to ACGME websites, the SNS, and the ABS websites, and the milestones. So all of those are there for your reference at any time. So we'll
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start off with a little bit of history. So we'll take a look at early neurosurgical education, which was really entirely
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apprenticeship-based. And, you know, at our institution, it was started by Dean Dewitt Lewis, who was the first vice president of the SNS Harvey Cushing was the first president of the SNS. He
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was doing transfacial and transphenoidal surgery a hundred-some years ago. And there was no residency program. The first residency program was started by Adrian Verbrugen. It came from Mayo, and
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that, again, was entirely an
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apprenticeship model. And then Eric Oldberg really formalized it and fused it with the UIC program And it was all entirely observational and apprenticeship with a county experience and then a private
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experience. across the street, which is similar to most programs back in those days. The available textbooks were very, very sparse. In fact, I own most of them because some of the senior
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faculty at our place, when they would retire, they knew I wanted them. So I've had a look at most of these things, and there really wasn't much. The diagrams were very, very sparse, almost no
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imaging and so on. And as far as multimodality education, it almost didn't exist The SS was really a traveling club, people going from institution, institution watching each other operate, and
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then doing some video, and that was available really just to select few within the SS to see how everyone else did what they did. So when you consider the ideal principles of resident education with
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progressive responsibility, physician ship, technical skill training, multimodality education, a broad volume of operative cases and following the science of learning and memory, the things that
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we think about today today, personally none of it existed at the time.
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perspective. Some of you may have heard of Paul Busey. Paul Busey was chairman of neurosurgery at Northwestern. I've always been a fan of Paul Busey because I was a medical student there and his
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portraits are everywhere and everyone would point to them and so on. But he was president of the SNS, president of the academy, I'm sorry, the AANS and the chair of the ABNS. So just listen to
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Paul Busey. Kim Clark here is interviewing Paul Busey back in about 1980. Paul Busey saw just the evolution of neurosurgery from starting in 1927
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to finishing in the 1980s. So just give, listen to his perspective.
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Seems not to be I came to Chicago immediately after my internships
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at the House of the House Ford Lending Drug. That was in 1928.
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PGY2 The only neurosurgeon in the hospital. In October of 1928,
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they had a PhD. They don't have a brain tumor. And although I had never operated on my own before, I had learned how to open a skull from the nurse there's another four now so go.
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operator and the other residents and in terms that the Florida hospital did not like to assist him because it took too long. So I took over and assisted him on most of his operations during that time.
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I also, we had to spend in one month in hip-hop.
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Can you show me how to do it? Sorry.
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Yeah. So you can get an idea. What am I doing? You just want to meet with me.
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Is that better? Good. All right. So you get an idea of early neurosurgery,
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very, very poor supervision, very little oversight. And by the way, Percival Bailey was the chairman of neurosurgery at the University of Chicago in 1928. He had done one operation in his
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training, one operation. He did that
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with Harvey Cushing Literally one trigeminal neuralgia operation.
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He spent his entire residency in the lab working on brain tumor research. So that was the level of supervision and, you know, thankfully it's all evolved from there. And I think that if you think
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about Paul Bucey, I'm sure he would be very, very in favor of what's evolved. And that is progressive responsibility
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and lower supervision over time Nobody is starting off as a. you why to unassisted anymore. And I think he'd also agree from what I've heard of him with the idea of competencies. I did my entire
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residency in the pre-competency era. These are all things that were implicitly understood and that you were supposed to learn it somehow, but really weren't explicitly taught. I think that he
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probably would agree with oversight from a national standpoint. This is what residency programs go through now every year, a self-study, and then every 10 years, a site visit. So I think he
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probably also find this to be a bit bureaucratic and overbearing, and this is what we go through now. So when I think about problems in neurosurgery, resident education, from the time that I
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became a residency program director in 2005, there were internal and external problems. The internal problems, I would say, were variability in education between programs, some with better
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education. programs than others. Very little simulation training. It was tough to define what a good resident was. You just say well that's a good resident. It was kind of hard to say why. We
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weren't really good at showing residents the way to success. Written and oral boards, I think, were a mess. The written boards, they're looking really at factoids. And oral boards, anybody
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could show up with any case and could fail you on that case with really with no standardization. And we didn't really have much of a way to show people earlier in their practice. So if someone
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finished their residency and they're floundering in their first couple years, we had ways of finding out who that person was and punishing them, but not really helping them. And there wasn't any
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organization in neurosurgical societies. Everyone was doing their own thing independently and there was very little diversity of residents. From the external standpoint, there was a poor service to
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educational balance. Residents were doing things like drawing labs and pushing patients to see. T-scanner and all this sort of stuff. Everything was lecture and book-based. We know that there's
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better ways now. There was very little science of education. There was no professionalism or communication education. We didn't really think about caring for the caregiver, and I can think of
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several instances of resident suicide in Chicago in these times. 'Cause we really weren't paying attention to people who were overstressed and failing. And we didn't train the trainers. There
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wasn't much education of the educators There was match chaos. And duty hours were finally changed in 2003. A lot of this was driven by the ACGME, the national governing body, and they did it in
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the usual ways from a top-down centralization standpoint. The United States neurosurgery was really sort of an outlier and considered the bad boy of the team and really didn't cooperate initially,
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but we eventually came together and we, became coordinated and we created a thing called the Summit where everyone would come together and figure out who was going to do what. So part of the problem
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was there's a lot of neurosurgery organizations. The SNS, founded by Harvey Cushing's the first society, Dean DeWitt Lewis was the first vice president. And they were doing everything initially.
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And then everyone's come to decide that really all the SNS is gonna do is US. resident and fellow education. Double AS was the second society and then they're really gonna do education and an
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advocacy, the academy's really focusing on research. The ABNS really certification, the inner urban, the NSA, the CNS, all education. So there was a time when everyone was doing a little bit of
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everything and the summit really helped to organize that. So when we look at the timeline of the changes, we start off in 1999 with the ABNS starting maintenance of certification. That was a
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national trend and we did it, starting in '99. the Society of Neurological Surgeons created CAST. Before this, fellowships really weren't very well accredited. It was difficult to say what
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fellowship was good and what wasn't. The SNS really jumped on this and it's turned into a huge success. The 80-hour work week started in 2003. The summit started in 2010, 2009. Neurosurgery took
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over its intern year. Before that, it was run by general surgery So we realized that we needed to train residents who were brand new, green, right out of medical school. And that's what started
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the boot camp courses. The seven-year residency started in 2012. Before that, you could do six or seven. And then in 2013, milestones. And then 2018, that was revised. And then we started to
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get into quality projects in 2019. Just breaking up who did what and how they did it the ABNUS had a lot of. contributions in this time, and Lindo was a part of that, Langston's a part of that.
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The ABS was established in 1940
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as a reaction, because the American College of Surgeons was about to start certifying neurosurgeons. The American College of OBGYN was talking about certifying neurosurgeons. So thankfully, the
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neurosurgeons came together and organized themselves. Paul Bucy was actually the first secretary of the ABS and later became chair. So he had to do one year of internship, three years of residency.
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That later changed to four years. 36 months of neurosurgery came in in 1979. And now it's 84 months, which 54 months have to be in coronary surgery training. And the most variability comes in
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those 30 months of electives. Those may come from research. It may come from PhD work may come from internal fellowships
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The ABNS written board, thankfully, has changed a lot. The boards that I took, Marvin took, a lot of other people in the room took, were really more factoid. So every year, you would have to
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rememorise the glycogen storage diseases in your lipid storage diseases. And I'm pretty sure that none of you have ever seen a lipid storage consult in the emergency room. But for some reason, that
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would dominate the neurosurgery abs written boards. All of that has been gotten rid of. We do a really thorough job of asking the question, is this a factoid, is it clinically relevant, and we've
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just been getting rid of that stuff. So it's much more clinically relevant. But at the same time, we're asking for a higher and higher pass rates. The neuroanatomy exam, residents have taken this.
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I don't know how many attendings here have taken this. It's not easy. I'm a cranial neurosurgeon, most of it's cranial and it's not easy, it's tiny microsurgery. But we do ask residents to get to
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100. We've just softened that to 95. You get three attempts. There's only three sources. So it's a limited source. You can actually get it done. But it's good to see that residents are starting
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off with the same baseline of neuroanatomy and reality were applied neuroanatomy as surgeons. So it begs the question if chat GPT can pass our boards, why do we really need to have written boards
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anymore when you can just pull something up? And the answer to that is, well, chat GPT isn't always right. In fact, sometimes it'll hallucinate and give you something that's really, really wrong.
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So it is important for you to carry around your own level of basic knowledge. And also begs the question, well, why couldn't chat GPT write these questions? And the answer is it can. Doug
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Kansioka and his team, especially Eric Orman, figured out ways to
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get their own large knowledge model to work with Chachi. to figure out how to write questions for the ABS. And we just approved doing this last month. So we're going to be writing questions through
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chat GPT. They're not gonna be scored. They're actually very good questions. If anybody's written a question, it's not easy. Now we have to come up with 10 every year and anybody that's written
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these questions to come up with a fair question that passes the muster of the ACGME is not easy So we're gonna have these things on the exam. They are not gonna be part of the score. We're just
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gonna do a trial and see how people do with these questions. The oral boards thankfully have changed as well. Like I said, in the old days, anybody could show up with any crazy case that only you
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are seeing and other people are not seeing and you could fail on the basis of that case. That's all been changed. These are now standardized questions I'm sorry, resident applicants or candidates
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for ABS certification.
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are asked to submit 125 sequential cases with imaging with three month follow-up. And now the past rates are about 80 to 90. I think the boards are far more fair than they used to be, far more fair.
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We're also asking people to submit their first 10 cases in practice. This allows us to get an initial look at candidates' cases right out of the shoot when they start their practice so that we don't
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find out that there's a problem after 125 cases. So I think that's a good idea just for that initial check. And people who are going astray, well, they're gonna get a phone call from either me or
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Paul Camarada from the credentials committee, just asking them what's going on, why are you having problems? And I can tell you from the sample size that I've seen, it's almost always people have
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taken a bad job. It's not necessarily they're a bad neurosurgeon, they took a bad job They're in an isolated place with - And those senior mentorship, their health care system is demanding that
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they take care of everything from mid-basular aneurysms to respond to lotosis. They don't know how to push back against that. Some of these folks just need to get a different job or they need to
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find senior mentorship.
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Collecting all these cases gives us an amazing look at early practice. So the post cases, this is what everyone submits all of their cases, their 125 cases into And now over 100, 000 cases. So we
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get a really close look at what people are doing in their early practice. So this is going to give us an idea of cranial versus spinal, adult versus peads. Where are people taking positions? I can
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tell you that academic positions are going way up, private practice is going extinct. People are either joining healthcare systems or they're joining, say UCLA takes
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a hospital somewhere in the community and now is staffing that hospital. It also gives us a look at re-operations, complications rates, safety, quality indices. It's really an interesting thing
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to study.
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Oral boards are better. And one more thing that I think that is better is COVID forced us to go virtual. And I don't think we're ever going back. I don't think that oral boards are going to be in
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person anymore. Besides the fact that it's expensive, time consuming, et cetera, for the candidates, it's a hot seat environment when you have somebody come in and they're sitting with two
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directors. No matter how nice the directors are, it just feels like this hot seat environment and you see people artificially do poorly because of that artificial environment. I just think right
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now the Zoom format is
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just easier for people to get through from an anxiety standpoint. We're also doing some proactive things for candidates We're trying to help them out in their early career. We're distributing the
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most definitive literature for surgical indications. People get in trouble for surgical indications, particularly spine. We're starting to distribute these
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CC literature to people ahead of time. We're gonna start that here in the spring. And then we're trying to give them more guidance and reminders on how to avoid being sent to the credentials
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committee where people were having trouble go So regarding the credentials committee, I've had a close personal look at this in the last few years. This is what happened last year. So we had 63
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diplomats in candidates reported to the credentials committee, typically by a state board action, typically something went awry, or it might be a medical staff action. And the issues are almost
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always professionalism and communication substance abuse, or indications, harassment, facts, et cetera, et cetera. This is just typical professionalism issues. And this is really important for
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the residents to understand. People lose their licenses for professionalism issues, not for technical matters. People don't finish neurosurgery residencies because of professionalism communication,
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not typically technical matters, so really pay attention to those things. The SNS really stepped up, created a thing called the Summit. The Summit is where everybody, leaders from all of our
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major societies come together every six months, and we talk about what are the next set of challenges and what should we do, who should do it. The first challenge that came up after the Summit was
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formed was Milestone. So we hadn't decided who was gonna take this on. This was an ACGME mandate. Nate Selden really took it on. I was part of the Milestone's Committee. Our Milestone started out
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at 48 Milestones. We got down to 36, 24, and then we revised it in 2018 We just keep trying to simplify it to make it easier. or residency programs to implement, because you can make them as big
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and complicated as you want, or you can try to simplify. We've really done what we can to simplify. And the milestones are really supposed to be a holistic evaluation of every possible evaluation
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that a resident can get. So the clinical competency committee of every residency program comes together every six months. It's supposed to be a biopsy of where the resident is at that moment in time
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And it's graded one through five, with five being fellowship level. Ideally, people will get to fours everywhere. You're not, you can graduate having not reached fours, but the goal is to reach
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fours in everything.
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To support the milestones and to acknowledge the fact that neurosurgery was taking on the PGY one year, we created the SNS resident courses. This is a combined effort, Tom Arigetano and Nate Seldin.
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starting one in Chicago, I was part of that from the beginning, but Tom really led it. And Nate Selden was doing something similar at OHSU. The SNS brought it all together. And for about a decade,
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every resident in America came to
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the intern boot camp course. And it was supported by industry. It was hands-on, senior faculty led, simulation-based, supporting the milestones, and acknowledging the fact that it's really hard
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for residency programs to train all of their residents in the simple EVDICP monitor, lumbar, drain, etc, etc, how do you evaluate a shunt, etc, where we can do all of that together. And that
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was the effort that started in 2009. And it was all put aside because of COVID, but it's going to start up again. And then there's a PGY2 course. About 90 of residents came for that. There were
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skill stations, how to open ahead. basic spine, et cetera, a simulation based, and then a chief resident course. What we saw over time, and I ran these courses for five years and then ran the
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committee that ran them for four years. Got a very close look at this, was the residence, and I'm sure it's true of your residence now, really don't want to listen to lectures. This is a
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post-lecture educational environment that we're in, people don't want to listen to lectures per se, they want to do pre-study and then small group activities and hands on. So we eventually just put
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the lectures online and asked for pre-study and then group discussion when you show up. This is something that's really swept through medical education, this article here's 10 years old, but I can
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tell you at our institution at Rush, it's all flipped classroom now Now, the problem with flipped classroom is number one, there's
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a heck of a lot of - front work for the faculty to put all these things online. The senior faculty get a little confused about it 'cause they're not used to this, they're used to their lectures.
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But the biggest risk is flipped classroom, it can become a skipped classroom. And that's been borne out particularly around the time of
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COVID at most medical schools, board pass rates have dropped in part because people aren't doing the pre-studying, they're not getting the basics in. Nonetheless, I don't think we're going back.
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At the courses, we would do skills training and assessments. We've gone over a lot of different simulation models over time, and we tend to keep the ones that are best. But we also put together
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universal checklists, things for residents to take home, for every procedure they ever do. There's universal preparations and checklists go through. There's a. a microsurgery skill station put
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together by Bernard Bendock. Obviously, microvascular and astomosis is a rare operation, but it is a good opportunity to practice under the microscope under senior mentorship. So what's really
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changed is that it's multi-modality and simulation-based training as opposed to lecture-based training as it was in the past. And there's plenty of science to prove that this is better learning Just
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so good, such is as long as the simulations are good. I mean, obviously, if the simulations are bad, then the training is going to be bad. I've been a part of a lot of these simulations things
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from skills training in the ICU to surgical training, et cetera. And I can tell you, the technical training goes a lot better than the professionalism and communications training. It's just
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difficult to put together simulations or group discussions of professionalism and communication that are meaningful for residents.
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As far as the science of learning, I think we're getting a lot better at this. This is the Gotsky social learning theory. Essentially, I think a common sense notion, but there are things that
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residents can't do and shouldn't be doing. There are things they can clearly do and don't need to do anymore. And then there's this area of the proximal development, zone of proximal development,
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where they're on a growth curve. They're on a learning curve. And that's where residents should spend most of their time from a technical skills standpoint. There are scales that help assist this.
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This is the tag scale. So when you look at tags, it's essentially these are things that faculty can do from teach and demonstrate all the way to solo and observe depending on what the resident is
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capable of that time. And then keeping track of that, so each of the faculty know where the residents need to continue to grow. Mike Hagelin ran the SNS courses for three years and he instituted
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that within the courses.
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But what he put together was an app. We've actually used it at Rush, but the app is something that the resident and the faculty use after each operation. And it breaks down the operation by stages
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and says where the resident is at. Are they done? And they really just need to learn that next step to just develop just an idea of where their learning scale is. So that brings up the question,
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what makes an expert technical neurosurgeon? There's a lot of machine learning work being done on this, looking at actual surgical video or simulation of surgery videos and breaking down and
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comparing it to external validation by surgical experts about what makes somebody good. So you'll take novices, intermediate surgeons and then expert surgeons and then break down their surgical
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steps and figure out what makes somebody really good.
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There's correlation and causation, and they're not the same thing. So one of the correlations for an expert surgeon is speed. So speed correlates, but doesn't cause excellent surgeon. That's an
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important thing for the residents to understand. So getting in under the microscope and just moving your hands around fast is not the answer. The answer is, as surgery becomes intuitive,
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everything just moves more quickly. But what makes an excellent technical surgeon is no saccades, fluidity of motion, efficiency of motion,
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that your two hands or two instruments working together in a clearly organized fashion.
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When we had to go to a remote course model with the SNS resident courses, obviously there's something lost. The interaction between senior faculty and residents is lost. And it's very difficult to
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do simulation training remotely. In 2020, we had to do that the first time. We took a look back and roughly half of residents were involved in it rather than all of them. They rated the course
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good to grade about 80. The costs, of course, dropped dramatically. The faculty hours dropped dramatically, but I'll also say that the quality dropped fairly dramatically because now we would ask
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the programs to do the simulation on their own at their place. And for the most part, it really didn't happen So we're bringing those courses back. Thankfully, Linda has found the money to make
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those courses happen as the asset is treasure.
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Anyway, so the boot camp courses are back on for July.
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Professionalism training has always been the most difficult. I love this quote. This is Arthur Conan Doyle from 150 years ago. I believe that this is very true that you can learn from your life.
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professionalism in a passive way. I do think that by observation, by watching your senior faculty, you can learn. I don't know how well we can train professionalism. We'll get to that in a minute.
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As far as wellness in 360 of ours, historically, these were not really issues. I put this up. This is again from the SNS archives. I'm talking about neurosurgical wellness. Just read this thing.
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This is by Cushing in 1924. Cushing wrote about an occipital meningioma by good fortune, totally removed. I wish I could say as much for the
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last case of supercellular tumor, which I lost on the table from a torn carotid. I have not had such an accident for 10 years, and it almost made me give up surgery as a job. So imagine Harvey
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Cushing four years after founding the SNS, thinking about leaving neurosurgery over an intra-operative disaster. Understand that even a person like Harvey Cushing who we all think of being this
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God-like figure that could do anything and wasn't bothered by anything. Well, you know, these things bother everybody. And I think it's useful that we're doing this sort of caring for the
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caregiver, worrying about how people are feeling as they're taking care of patients in neurosurgery. As far as 360 evaluations, obviously, these were not really things. It wasn't a thing when I
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was a resident either.
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And the earliest example of a 360 evaluation, I could find in the SNS archives was this. This is about Alfred Addson. He started the neurosurgery program at Mayo Clinic. He was a good surgeon of
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the Western type. On occasions, he was fuming and bombastic until his staff cured him by taping some of his tirades and playing them back to him. He also did a little fuming when he retired, but
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his early deaths seemed to justify it. So every time you use an adson, the
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sector or an adson clamp or something, think of this. That's Alfred Addson. There really was very little feedback for residents or senior faculty on their behavior.
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As far as training professionalism, there's a lot of literature, general surgery literature, et cetera, about training professional. This is the NYU group. They did a really
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deep dive into training professionalism. They really made an effort. They believe that you can train professionalism and that you can get improvements in things like communication and interactions
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within the team. I think that's probably true, but I can say, as we were discussing last night, a lot of professionalism comes in with your parents between the ages of zero and six, as Langston
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put it last night. And some of that is it's tough to make up for it if it didn't happen when you were young. We put this together based on our SNS, the resident courses experience,
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was more difficult. The surveys of the professionalism and communication modules always underperformed the skills, simulations. In the end, I have often referred residents to some of the books
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written by neurosurgeons that I personally know and trust on communication and professionalism in the neurosurgery.
37:01
There's been changes in the match and I really think that this was a major advance. Lola Chambliss is running our SNS Medical Student Committee right now and I think Lola's done a great job along
37:13
with her committee. The first change was preference signaling. Preference signaling was, I think, essential because resident applicants were applying to 80 to 100 programs. So how do you know
37:25
that somebody's actually interested in your program that wants to match? So somebody gets 80 interview invites. Well that just means that other people are getting fewer. interview invites. And
37:35
they might remotely do 40 of those. So there's this disproportionate distribution of of interviews. So preference signaling a year ago, we did eight. So five, five out,
37:50
five outside of your external rotations and three, three of your your rotations that you did, we've changed that to 25. Based on the experience of orthopedic surgery, we listened to what they did.
38:03
There was a lot of satisfaction among residents, and I'm sorry, resident applicants and the residency programs. We'll see how it does this year. It seems to be better because it really, it does
38:13
seem to match people to where they want to be.
38:17
A cap on externships was placed a year or two ago, just suggesting that there be two external rotations and one home rotation. That's a recommendation. The SNS does not have control over what
38:30
medical students do, but that's a recommendation. And we have a universal release date for interviews. There was a time a few years ago where residents, resident applicants had to have their phone
38:41
with them at all times because if they didn't sign up for that interview immediately, those interview spots would be gone.
38:50
We went to the Zoom model for the last couple of years because of COVID, but the transition seems to be going back to people being on site Is this on site now for you guys? You're still zooming?
39:04
Yeah, I personally.
39:11
Yeah, I personally don't have a problem with that. When you think about it, all the travel really,
39:18
it's a disadvantage for people who can't afford to do all the travel. And then you have all this travel, you say you go to 20 programs, and then you go back for 10 second looks, the second looks
39:29
are a problem too, which we're trying to rationalize. The second looks, people, what we always tell resident applicants is you do a second look for you, not for us. We're not going to grade you
39:41
based on whether you came back for a second look, but I think that has to be rationalized. And then there's a standard standardized letter of recommendation, really more of a checkbox with some
39:50
text, and then looking at this, Lola actually took a look at this with an AI program and look back, and there's certain words that are predictive of matching well, and it's sort of predictable,
40:02
it's AOA and excellent and outstanding, etc.
40:09
This is a paper we did a couple of years ago in trends in US. neurosurgery residency over the last decade. And the first trend you'll notice is there's a lot more interest in the topic. So there's
40:19
a lot more peer-reviewed publications
40:22
about neurosurgery education. There's also a lot more cases being done or at least being submitted for review by the RC.
40:34
In those cases, the growth curve really is in endovascular and in spine surgery. And some of that has to do with a switch from six to seven years, but some of it is that we're just tracking things
40:44
much better.
40:48
Demographic trends,
40:52
the number of the percent of women in neurosurgery residency training in 2009 was 127. By 2018, 173. And today it's over 20. I don't have the most recent number, but it's well over 20 now. The
41:07
number of programs 100 to 115, it's now 121. Regarding women in neurosurgery, this is an AI rendering by the way of the future of neurosurgery and the AI chose a woman for it. I also like that the
41:22
woman's left handed being a lefty myself. And by the way, left-handers are highly disproportionately represented in neurosurgery. It's roughly twice expected.
41:35
The wins committee does a great job of keeping track of what's attracting women to neurosurgery and what's keeping them out of neurosurgery. I do have a stake in this. This is my family, my wife's
41:47
a neurologist. I have two daughters in medical school right now, one's planning on being a neurologist and the other one a neurosurgeon. And this is my daughter having done her first burr hole as
41:59
an M2 at Northwestern. They're on the right. So I'm watching this very carefully. And obviously, I'm getting feedback from her all the time. about what's attracting
42:13
her or attractive to her and not attractive to her about neurosurgery.
42:19
Regarding match
42:21
rates and so on, it's pretty stable. The overall match rates about 60. The overall US MD match rates about 80.
42:31
What is, I think, still disturbing is there's a nutrition rate of about 26 per year, and you average that at over a seven-year residency. The attrition rate's roughly 18. I don't know the
42:44
breakout of how many leave of their own accord or not of their own accord. I can tell you for sure that of those that leave not of their own accord, it's almost always professionalism and
42:56
communication issues.
42:59
And then a couple of more things just to think about and maybe discuss after I'm done here or we're just about done The question of seven year program. We were one of the. last programs to go seven
43:10
years, we were at six. We felt we could get it done. Our residents were getting 1, 500 cases done in six years, the average of a seven year program is about 1, 100. So we thought, well, what
43:20
are we gonna do with that extra year? So we wrote a couple of papers on this recently. Based on a survey we did, 121 programs, 91 responded. We asked, what are you doing with that seventh year?
43:32
And I can tell you what it's evolving into It's largely evolving into an internal fellowship. So that's really what's happening. And the growth of in-folded fellowships has been exponential since
43:44
the seventh year was added in, mostly spine into vascular, functional, neuro-oncology, and so
43:51
on. And if you look at the number of programs who are doing this and how many in-folded fellowships there are - I mean, there's a couple of programs out there with nine in-folded fellowships five,
44:02
six, four, three, pretty common. So,
44:07
in folded fellowship, seems to be what's happening, which begs the question, well, I mean, couldn't you really get the training done in six years?
44:16
If what you're really doing is forcing a fellowship, and then people go off and do yet another fellowship. And then when you add in the problem of, well, about 60 of people who get into medical
44:26
school now are doing at least one gap year, one, two, or three gap years. And then 30 of residents - sorry, 30 of medical students who match in neurosurgery are doing a research gap year. And
44:42
then you add a seven-year residency and maybe a fellowship. And then your board certified three years after all of that. So we're pushing right now to people being board certified at the age of 40.
44:54
At some point, we got to pull back. I mean, that's my opinion.
44:59
The nice thing about seven years is you can do an enfolded fellowship if somebody really is not quite there yet You can do something else with them. They can do your research, et cetera. But I
45:08
think it does beg the question, a win is enough enough as far as stretching out, training and neurosurgery to a board certification at 40. And now counterbalancing that is the rise of resident
45:21
unions and the impending duty hour reductions that are probably going to come. The information that I've gotten from the ACGME at the board retreat last month is that we're almost certainly gonna see
45:35
another duty hour reduction. And that will either be 70, 60 or 56. The EU is at 48 hours. So I'll just ask the question of the residents right now. If you had your choice to keep it at 80, but
45:52
go six years, or go to 60 hours or 70 hours and keep it at seven, what would you choose? Because there was a push within neurosurgery to consider
46:05
maybe a six year versus seven-year option. And that literally just died at the ABS retreat last month because of this issue right now. So what's happening now is we're probably going to go to a
46:20
shorter work week. So these unions, they're all SEIU-based are in eight states now, Northwestern just became union last week. And
46:32
this is on the website, the SEIU website. These are the issues that they're saying, but in asking people last night at dinner, the primary benefit that you've seen is probably more in the ways of
46:43
salary and stipends for living and so on. So with that, I hope to stir up a little bit of discussion, both amongst the faculty and the residents. So in looking back at the initial problems that I
46:59
mentioned from 2005, I put green here at things where I think we really did make some progress. and whites and things that I think still need to be worked on. So showing the way in residency and
47:11
early practice, we are working on the early practice model from the ABS standpoint. Showing the way in residency is individualized, residency by residency. I mean, you can show somebody their
47:22
milestones, but what does that really mean in a tangible way for each resident? I do think that we still have work to do on the diversity of residents We still have work to do with science of
47:36
education and training professionalism and also training the trainer. So, you know, when I think back about what would Paul Bucey think of neurosurgery training now, having had a literally a
47:47
50-year career in neurosurgery, and, you know, going from being in op-read foresters, operating room, holding a lamp wearing a suit at the beginning of his training to the CT scan at the end This
48:03
is literally the first CT scan. ever to show a brain tumor there in the right frontal lobe.
48:10
Having seen all of that, all of the change and all of the evolution and the fact that his residents all excelled in areas that he did not teach them, I think he would understand the evolution of
48:22
clinical practice and the evolution of education will go hand in hand. So in conclusion, I would just say that we've had imperfect but real progress. There's still lots to do and lots to debate,
48:34
but I do think that we are making an impact. So thank you for your attention, I'm looking forward to QA.
48:45
Yeah, great job Rich. It's great having you at the forefront and helping to push these things and to protect our field and do all the things you've been doing. So thank you for that. One thing
48:58
that we've seen certainly here, as you mentioned, is the increase in women residents. You know, we're probably over 40 in our program, which I don't know where that is nationally, but I'm sure
49:08
it's probably in the upper part of it. And you mentioned in your talk somewhere about 12 to over 20 now, since like 2009. So almost maybe close to doubling, depending on what the number is, where
49:21
we've still struggled both in our program nationally as those from underrepresented groups have been totally flat during that same time period. What are your thoughts? What are you guys doing at
49:31
Rush to help kind of increase diversity from those underrepresented medicine? What do you think nationally that we can do or should be doing to kind of get that flat curve more and upward
49:44
Yeah, I mean, the easy answer is it's a pipeline issue of people, those folks need to get into medical school before we can rank them. So there's a pipeline issue, so there's a delayed response
49:58
of getting people into the right colleges, the right pre-med curriculum, and then into medical school. You can't match somebody who isn't there. So I think that's part of the problem. I mean, we
50:08
have three African-American residents right now, and we've graduated many I mean, that's not a problem for us at all. But I know for some programs, it is a problem. And I think that there's also
50:21
-
50:24
there's an all or nothing phenomena that we've seen. So our African-American resident applicants who see get on our website and see three other African-American residents feel like, yeah, this is
50:37
maybe a place where I'll feel like I fit in. whereas that might not be the case in the Great Plains programs, who knows? I also think that that's a phenomenon with women and my daughter strongly
50:50
confirms that. So we graduated five women through the years and then we had a stretch where we had no women in our residency program. So you get on our website and it looks like a fraternity house.
51:04
And half the guys in our program played sports in the world. Played sports in college and it looks like literally like a locker room and smells like
51:15
one at times too.
51:18
So some women really just didn't feel comfortable being the first into that crowd. And I can tell you seven years in a row, seven years in a row, we ranked a woman number one and they didn't rank
51:29
us number one. And they went to places like OHSU, Nate Sellin, a good friend of ours. I mean, I was visiting professor there in October and more than half of the residents are women. So there's
51:42
this phenomenon of more tends to bring more. So places like UCLA, OHSU, lots, and then Rush, we can't get one. We have the last couple of years. And I thought, I'm gonna have to wait for one
51:57
of my daughters to go into neurosurgery. Sasha was interviewing with
52:04
us last year. She saw that. I mean, we have, yeah I mean, tell me if I'm wrong, but when you get on the website and it's all guys, yeah, that might be a deterrent for women to even apply.
52:21
Your point, you know, they've done studies and they've seen that if you look at people underrepresented groups, they tend to concentrate in certain programs. And so there's programs that have a
52:31
history of having a significant number, and then there's others that have no history And it's really an interesting kind of curve with that. Yeah, and I do think some of it is the all-nothing
52:42
phenomenon. Some of it is, I think some people want to be in Chicago and don't want to be in Nebraska. And that might be a democratic choice or it might be other.
52:57
Before we talk, Dr. Byrne, I have a question regarding the reduction in duty hours from a national neurosurgery leadership level. Do you think that people are considering that we're not doing as
53:08
much in the way of busy work as far as collecting labs in the morning, we have more APPs and therefore it's an appropriate reduction or do you think this is more of a some people might say newer
53:20
generation work-life balance sentiment that's driving the conversation?
53:29
Probably both. I can't I can't tell with a great argument for either one of them, I think
53:35
it's probably both.
53:38
I do think the residents are getting more done now in 80 hours and we used to get back in mind for any days because there were times when you became full body at 10 pm. or you're putting in all the A
53:53
lines and now you have neuro critical care doing it and so on. So you're getting more meaningful training. I mean, there was a time when the junior resident's job was to find films running back and
54:05
forth to the film vault and picking up films and then chasing down Dr. Berger and signing Dr. Berger, here's the MRI's. You had to break into the film vault just getting into the films. The film
54:17
vault would close at seven or eight. And so you and your colleagues would break into the UCSF film vault to get into the film to show Dr. Berger. Yeah, well, you know, it's part of the training
54:25
Well, as you tell, you got to
54:29
go to college. Thank you. There were certain radiology attacks that we could bribed with certain liquors. They would be our best friends. Yeah. Yeah, we have some here. My name's
54:44
Sandy. I'm scared to be there. Yeah, I mean, I have to always not to get good with Sandy. I want to ask you a little bit about professionalism, issue and nature versus literature.
54:56
If we just narrow it down just for discussion and say indications, I think part of it is that if the residency program doesn't teach indications, shame on program, but someone who has true
55:10
professionalism problems is taught that yet it just goes off for monetary reasons or whatever. I just wonder what your opinion is. I personally think that cannot be fixed. That can be monitored and
55:30
one thing I think is super powerful here is that we have very good MM conference, which naturally tends, you get to sit there and present this in front of your peers and it tends to hold things back,
55:41
but places, solar practice or other places may have weak MM process where people can just go off and veer off and do unindicated operations. I don't think, I personally don't think you can fix that.
55:56
I think you're right. I think that some people are externally motivated, money, prestige, whatever. I also think that there's probably a disproportionate share of those folks who practice in
56:08
terms of surgery because it's perceived that way.
56:15
All we can do is that which is fixable. And that is number one, identify that person, not match them. And then number two, teach those indications as you pointed out So that's something that in
56:28
the ABS, we have the continued certification. We have all the best literature on indications for everything. And we wait for people to go through their continued certification modulus to look at
56:41
those. We want to be proactive now and send those papers out to people who just finished their residency, who may not really understand that spinal fusion Yes, yes. There are guidelines for what
56:56
should be used and not used. And actually one of the biggest problems we have in spine right now is people come out of these complex spine fellowships where all the discussion is percent correction
57:09
per level. And it's not about what really needs to get fixed and what doesn't. So do you see people's - well, my professor would say, I need 11 correction on this level, which means I have to use
57:20
the next level
57:22
So some of it is just the confusion of how much of it is sagal balance and how much of it is
57:30
that's normal level, you know, a lot.
57:35
Thank you very much for your call, Doctor. What is your opinion? Because the majority of the graduates in the research in now, they do a spine surgery. What's going to happen? Because you're
57:45
talking about the history, almost necessarily the brain part is almost going to go on the side, all you have to have only. Brain research and spine numbers. What is your opinion? What is the
57:57
derivative of your future?
57:59
So the post data, I thought it was gonna be 75 spine 25 brain 'cause that's what I've heard, but the post is 60, 40. So there is still a fair amount of brain surgery being done.
58:15
Spine, it just so happens that there's a lot more disks out there than there are lobes And I think that's been a great deal about advising. People are outliving their spines now in a way that you're
58:29
not really outliving my brain. So I think that's part of it.
58:34
I don't think that's particularly gonna go away. I think what's gonna really flip the wings of spines surgery eventually is when they do value-based hair or a bindling. That's gonna flip some of
58:45
that. And people will probably fade a little bit from that But for now, those are the cases that show up in people's clinics.
58:54
You mentioned how professionalism issues tend to really be the problems you see with residents but also faculty as well, for sure.
59:04
Have you figured out a way to assess for professionalism and their potential for being good professionals in medical students when you're making your rank list and figuring that out? Because if
59:16
that's really the main issue, we need to be able to better discern that, right? Because we see the CVs and publications and we see all these things that sometimes drive match lists and things. How
59:30
do we get back towards looking at those things that are really the determinants of if people who are successful and finish the program? As far as professionalism goes, I think it comes down to
59:39
letters and phone calls. You have to read the letters written by people that you know and trust. And then when you're really putting your rankings together, you give them a call In particular, if
59:50
there's any questions at all about - we're not so sure about this person. Because you can easily, if you're not a good person, you can hide that in a 15 or 20 minute interview easily. It's kind of
1:00:04
hard to hide that in a month. And it's the residents that usually pick up on it, not necessarily attending. Everyone cleans up their behavior around you guys, but with the residents, that's when
1:00:14
you're really good to know somebody.
1:00:18
Right. There's been a move from both an undergraduate and medical education away from standardized testing and away from grades.
1:00:27
Is that something that these boards are paying attention to or are worried about? Is there, do you anticipate that the pendulum is gonna swing back the other way? Yeah, we talked about this last
1:00:36
night a little bit. There are some colleges that have
1:00:41
been locked, absolutely T, A, C, and T's, and now they're coming back to you. And in part people, they don't really know how to,
1:00:49
70, 000 applicants with 120, 000 applications to UCLA over your house. How do you decide? It's impossible. So I think that it's a bit of a pendulum. At the same time, it really takes the
1:01:03
pressure off the medical students at2 in medical school right now. You know, my wife is definitely one of these all over at mothers and my daughter's all they do is tell her that they got 100 on
1:01:18
every test, 100 on
1:01:21
the pressure is gone. They don't have to tell her a number anymore. At the same time, if board scores keep dropping as a result, and that's what has been seen over the last several years, it's
1:01:33
really a question of the pendulum that we're going to swing back, and I don't know that answer. Right now, the only board that we see is the second board, and by then
1:01:45
Resident applicants have already decided on their field. And it's almost too late to turn back. So you're going - you're gunning for neurosurgery or plastic surgery in T. And if you get this low
1:01:57
board score back, you're really in trouble at that point. Because you're not likely to match in that field. And all the research you've done, all the chatter you've done, is in that field. So in
1:02:07
a way, it disadvantages the medical students in some way. And then finding it disadvantages the medical student from a smaller medical school So instead of people saying, well, that person had a
1:02:21
270, but they're out of Oklahoma versus the person who had a 320. So that was a way for the person that the lesser known medical school to be even up to the playing field. Now that's a lot.
1:02:39
You mentioned sort of as a great talk by the way of registering. You mentioned also a throwaway that private practice is going extinct Yes.
1:02:50
just a pretty major thing to say in an off-hand way. And I wondered if you could elaborate on your thoughts on that, on what maybe what's driving it and whether or not organized neurosurgery can do
1:03:00
anything about it or wants to do anything about it or should do anything about it. Yeah, I'm in favor of some practice in neurosurgery, there ought to always be free range neurosurgery out there
1:03:12
somewhere, okay, because those of us that have happened need something to compare ourselves to, right, so whether you're at UCLA or Sutter or Kaiser, you're captive, and they'll put a restricted
1:03:23
comment on you that may eventually come down. So there needs to be something to compare that to. In Cook County, Illinois, we're talking about, I don't know, five million people. There's not a
1:03:36
single practice neurosurgery, not one. 25 years ago, they were everywhere, and it's all financial The bottom line is our overhead. to be a neurosurgeon cook county, if you're overheads 400 to
1:03:50
500, 000 a year. So January 1st, figure I'm writing a chapter for 500, 000 dollars. Medicaid is the fastest growing payer.
1:04:01
And it's simply that the math does work. And what really happened is
1:04:08
1997, 1997, CMS took professional fees to neurosurgery, drop them by 30, and then at the same time raise the DRGs for neurosurgery for hospitals by 40. So
1:04:26
the model switched from your professional getting professional fees through your free agent, like in baseball in the 1970s, where your actual value is bringing people to the stadium, the stadium
1:04:40
being the hospital So in reality, I know the math on this very well, but in our institution, We get1 professional fees for every10.
1:04:51
The hospital gets on the admission. Literally a trend to one ratio. So your value is in bringing people to a hospital. It's not in the operation that you did per se. I don't think that's ever
1:05:03
going to change. As long as that ratio is 10 to one,
1:05:07
you're a free agent. You're a person that brings agents to a hospital. Now free agency assumes that you might leave. And if you're unwilling to leave ever, there is
1:05:17
no bottom to which you'll be dragged, right? So you have to be free agent at some point. And it is kind of sad to see private practice disappearing in places like Chicago. I don't know what it's
1:05:29
like in LA. Are there real private practitioners out there anymore? Well, yeah, sure. Yeah.
1:05:36
I think part of it is RML practice is 230,
1:05:40
000 a unit for the one free policy. And I think in California, you think that cash is probably like 30 to 40.
1:05:47
you know, the caps are changing, but like you see we're self-insured, so it's actually the rates are better. And I think that's bottom line, right? It's the expenses to be in a, you know, in a
1:05:59
group, an academic group or an employed model is actually better than private practices days.
1:06:09
Question, thank
1:06:13
you for your talk. Very interesting. A question I got about the duty hours, the company made about, you know, it's either to, we either increase the years or keep the numbers of hours high.
1:06:22
It's a little bit of a false dichotomy, don't you think? I mean, even now, even if we don't go do phlebotomy, and I'm sure people have seen it as in the tendings too, like the hours that you
1:06:32
spend doing administrative work as inflated, like year after year, I'm sure for attendees as well as for residents And so some of the hours that are being spent and not. you know, even true
1:06:47
neurosurgical service hours let alone education. So what are your thoughts kind of about that and what its medical systems we can do to minimize that? Well, I mean, there was a time when we had
1:06:58
long hours and long residency, if you go to short hours and shorter residency, inevitably, you lose experience. So you're disraduating greener and you can say, well, okay, well, in Europe,
1:07:15
it's four or eight hours. But in Europe, just take a look at what happens in Europe. As an attending, you're essentially the person who opens and closes for the big professor. You're never really
1:07:27
independent until you become the big professor. So your residency has ended. You're a consultant, but you're still under the wing of the big professor. The way it's modeled here, you finish your
1:07:40
residence. You've got anywhere You got to take a job anywhere Sure. So the question is what is safe? What level of training is safe? Is it 1, 000 cases at 1, 500 is 500? I mean, there's a
1:07:55
gradient there below which maybe it's not safe to go out and practice, particularly for some of the more complicated things.
1:08:04
I think like a draw of neurosurgery for everybody is the commitment to the craft, irrespective of external work hour considerations and things like that. And to put it mildly been relatively
1:08:21
unimpressed with interactions with other residency programs that are more adherent to workouts, right? Well, work hours are primary consideration. My question is like, if these things are so
1:08:32
divergent, let's say ACGME requirements and work hours and the goals of training to become an expert surgeon by the end of your training, is there any mechanism to like leave the GME or a bird nurse
1:08:43
surgery to have its own organized system. So we can leave the ACGME and create a specialty surgical board. And that has been discussed recently. That doesn't mean that UCLA or a surgery can leave
1:08:59
UCLA, GME. Those are two different things. ACGME and your individual GME. Linda, if you won't happen to you, if you said we're pulling out all of these little GMEs. Do you know if we've ever
1:09:13
tried
1:09:16
it? I'm sure I know what we've asked. Yeah, I mean, yeah. Right. That's certainly not possible. You're not going to pull out of the California sister. You are part of the system. And yeah,
1:09:26
you're going to see a variety of dedications among physicians. You're going to see it within neurosurgery between specialties for sure. But yeah, there's an international thing. There is this
1:09:40
section about pulling out an ACGME That's on the left.
1:09:49
You mentioned that the SS has a two externship recommendation. I'm aware of many programs, including ours who have increasing
1:10:02
basically this decision. We're only going to take sub-eyes or preferentially mass sub-eyes, but if you only get two, the math just doesn't work out very well. I actually counsel medical students.
1:10:16
You should do, really pick your programs and do many sub-eyes because that's your best chance of matching. It seems like the SS is out of sync with what's actually happening out there in the SS
1:10:30
program. Yeah, so is it a suggestion? It's not. The SS has no punitive mechanism for telling the SS programs what to do or not do. These are suggestions that we hope people will follow at the
1:10:45
same time. When I advise my own daughter, she says, can I do three, I say, sure, go ahead. But what it ends up being though, is that she has less time to do anything else during her fourth
1:10:57
year medical school. So if you thought you would do a month of critical care, well, you're not gonna do that month. You're gonna do a neurosurical event.
1:11:09
Thank you very much. About the professionalism, I talked in this medical school for almost 20 years, with different years with the students. There are students who have problems. Whatever
1:11:22
you do, whatever you say. Dr. Yang was in my class years ago. And we said -
1:11:30
That was a surprise. That's a bad experience. And fortunately, the school is the one. They don't wanna get bad reputation to drop the estimate. Financially or also lawsuit There was one history
1:11:45
that I never forget.
1:11:48
For two years, she, that student tried to ask the first year, she had a problem, and the school, they knew she had so much problem, and they didn't do anything, they said, Don't say anything,
1:12:02
God, that's what she's going to do, she has both of them. If you touch, maybe, soon, soon, this is the problem, I think the medical school should be more cautious about training, but some
1:12:13
people, you can't change them, this is the nature, very rich, all of us know, not that you are bad, they don't fit in a medical field from the professional point of view.
1:12:26
Well, that's a universal problem. I'll just comment that you can't live in fear of lawsuits, in neurosurgery, you have to take risks, and not have trained you have to take risks, and as a chair,
1:12:40
I've been sued Thank you. I was sued by a residency program coordinator who I fired 'cause she wouldn't show up before 1130 in the morning and she was supposed to show up at eight and we went through
1:12:51
every process of you can't, you can't, you can't, you'd have to, you'd have to. And then finally I fired her and then within a day I had a lawsuit on my desk suing me for discrimination because
1:13:04
she was depressed and I should've known she was depressed. I mean, you can't stop that sort of thing And by the way, my institution, I wanted to go to court and I'll meet you in hell, I'll meet
1:13:16
you in court, no matter, this is ridiculous, okay? Everyone, I'll take you on rounds through the ICU and I'll show you depression. Okay, your units don't want to be in the morning, okay fine.
1:13:30
But our institution settled it and they just kind of laughed at me and said, Well, you know, Rivers, this is Cook County.
1:13:37
95 of these go for the plaintiff, no matter what we do. So we're just gonna write in a smaller check than we'd have to record. And that's just part of the cost of doing business.
1:13:49
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1:14:05
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